<style>
    .c-list{ border:1px solid #c2cad8; border-top:0px; display: block;padding: 6px 10px 6px 10px; max-height: 380px; overflow-y: auto;}
    .c-list li{ display: block; border-bottom:1px solid #eef1f5; padding: 6px 10px 6px 10px; cursor: pointer;}
    .c-list li:hover{ background-color: #eef1f5;}
    .c-list li i{ text-align: center; display: block; width: 60px; height: 60px; border-radius: 50%; overflow: hidden; float: left;}
    .c-list li i img{ width: 60px;}
    .c-list li dd{ display: block; height: 60px; padding-left: 10px;float: left; width: 80%; overflow: hidden; line-height: 28px;}
</style>
<div class="row">
        <div class="am-u-sm-12 am-u-md-12 am-u-lg-12">
            <div class="widget am-cf">
                <form class="am-form tpl-form-line-form" data-am-validator id="formDoSubmitDialogMy" style="padding-top:0;">
                <div class="widget-body am-cf">
     				<div class="am-g">
                        <div class="am-u-sm-12">
                                  <input type="hidden" name="Id" id="Id" value="{{.m.Id}}">
                                   <input type="hidden" name="Openid" id="Openid" value="{{.m.Openid}}">
                                  <div class="row am-cf">
                                      <!--<div class="am-form-group am-u-sm-12">
                                          <label class="am-u-sm-3 am-form-label">就诊卡：</label>
                                          <div class="am-u-sm-9">
                                              <input name="Number" class="am-form-field" type="text" id="Number"  placeholder="长度不超过20" maxlength="20" value="{{.m.Number}}" required/>
                                          </div>
                                      </div>-->
                                      <div class="am-form-group am-u-sm-12">
                                          <label class="am-u-sm-3 am-form-label">真实姓名：</label>
                                          <div class="am-u-sm-9">
                                              <input name="Realname" class="am-form-field" type="text" id="Realname"  placeholder="长度不超过20" maxlength="20" value="{{.m.Realname}}" required/>
                                          </div>
                                      </div>
                                      <div class="am-form-group am-u-sm-12">
                                          <label class="am-u-sm-3 am-form-label">手机号：</label>
                                          <div class="am-u-sm-9">
                                              <input type="text" class="am-form-field tpl-form-no-bg am-margin-top-xs" id="Mobile" name="Mobile" value="{{.m.Mobile}}" placeholder="输入手机号" required>
                                           </div> 
                                      </div>
                                  </div>
                                  <div class="row am-cf">
                                      <div class="am-form-group am-u-sm-12">
                                          <label class="am-u-sm-3 am-form-label">性别：</label>
                                          <div class="am-u-sm-9">
                                                  <label class="am-radio-inline">
                                                    <input type="radio"  name="Sex" value="男" required> 男
                                                  </label>
                                                  <label class="am-radio-inline">
                                                    <input type="radio" name="Sex" value="女"> 女
                                                  </label>
                                           </div> 
                                      </div>
                                      <div class="am-form-group am-u-sm-12">
                                          <label class="am-u-sm-3 am-form-label">生日：</label>
                                          <div class="am-u-sm-9">
                                              <input name="Birthday" type="text" id="Birthday"  class="am-form-field" placeholder="请选择出生年月" value="{{.m.Birthday}}" data-am-datepicker="{format: 'yyyy-mm-dd', viewMode: 'years', minViewMode: 'days'}" required readonly />
                                          </div>
                                      </div>
                                      <div class="am-form-group am-u-sm-12">
                                          <label class="am-u-sm-3 am-form-label">年龄：</label>
                                          <div class="am-u-sm-9">
                                                <input name="Age" type="number" id="Age"  class="am-form-field" placeholder="填写年龄" value="{{.m.Age}}" />
                                           </div> 
                                      </div>

                                  </div>
                                  <div class="row am-cf">
                                      
                                      <div class="am-form-group am-u-sm-12">
                                          <label class="am-u-sm-3 am-form-label">联系地址：</label>
                                          <div class="am-u-sm-9">
                                               <input name="Address" type="text" id="Address" class="am-form-field tpl-form-no-bg am-margin-top-xs" placeholder="请输入所在地址" value="{{.m.Address}}"/>
                                           </div> 
                                      </div>
                                      {{ if .m.Id }}
                                      {{else}}
                                      <div class="am-form-group am-u-sm-12">
                                          <label class="am-u-sm-3 am-form-label"></label>
                                          <div class="am-u-sm-9">
                                              <label><input type="checkbox" name="sync_guahao" value="1"> 挂号</label>
                                          </div>
                                      </div>
                                      {{end}}
                              	  </div>
                        </div>
            		</div>
                </div>
                <div class="widget-footer am-text-center">
                     <button class="am-btn am-btn-secondary" type="submit">确认</button>
                </div>
                </form>
            </div>
        </div>
</div>